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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> T A� ENVIRONMENTAL HEALTH DIVISION <br /> 0/�( 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED /00�`K <br /> IC*.pkt.IB Trlph"t.1 r <br /> APPLICAl ION IS HEREBY MADE TO 1 H BAN JOAGUIN COUNTY MR A PEMeT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPIANCE WITH SAN <br /> JE`•^VIN COUNTY DEVELOPMENT lE.C�ER 8-11101.3 AND THE STANOAW9 OFF SCAN JOAOVIN CO NTY BUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. !O 1 i <br /> J� DDREBS/OR(APN+/_�J' _J/•/ 4,2 /C./LY� CHY `�`�-�7� LOT TCSyIIZE�k-p� <br /> OLM�ER'B NAME �✓` / �/�n� � MONE3& - ' ov H <br /> ADDREC9 <br /> CONTRACTOR /,✓ADDRE.F LK/ %y/'(J/-/[/-j�--[)sPRHONE <br /> 6 ONTMCTOR UC/ PHONF <br /> -tl�� �{!✓ 1� <br /> T—OF SEPTIC WORK: NEW IN6—"T10 REPNIVADdIION ❑ DESTRUCTION❑ <br /> IND SEPTIC SYSTEM PERMITTED IF MBUC SEWER 18 AVAILABLE WHHIN 200 FEET OF BUILDING.) F <br /> P61C TESTI.)1 I HOW MANY <br /> II .ELATION WILL SERVE: RESIDENCE❑ COMMERCIAL❑ OTIIUX (� C7/l <br /> N HER OF LIVING UMTS: NUMBER/OF BEDROOMS. NUMBER OF EMPLOYEES: <br /> F <br /> R OF 60IL TO A DEPTH OF 3 FEET:Ci—B/•C(��1-1{f, PIT/BUMP 601E CNAMCTEII WATER TABLE DEPTH <br /> C 7 gORFAGE TARP ❑TYi'E/K1FO L.V/amu SLU' CAPACITY �C OO NO.COMPARTMENTS <br /> AEATMENT WANT❑ DISTANCE TO NEAREST: WELL�_� FOUNDATION � PROPERTY UNE 6 <br /> UFTSTATION E TYPE OF PU P SAND OIL SEPARATOR IENCLOSM SYSTEM)/ <br /> LL..-LING UNE O.B LENGTH OF LINES 171'��' /A�C�.J DISTANCE TO NEAREST:WEU,/�O FOUNDATION UO PROPERTY UNE <br /> FILTER BED OTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE //J <br /> MOUNDED WIDTH LENGTH .,,N DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE C/ <br /> S AGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE C <br /> B' B ❑WIDTH EENGTH DEPEH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> DISPOSAL PONOS [I WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE < <br /> 1 <br /> I I"^`BV CERTIFY THAT I HAVE PREPARED 71118 APPLICATION AND THAT THE W01N WILL BE DONE IN CCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES AND 81ATE UWe,AND RULES �J <br /> A IEGULATgNB OF THE BAN JOAGVIN COUNTY.NOME OWNER OR LICENSED AGENT'S MONAT C iIFIESTHEFOLLOWHNO:'ICER7IFYTHAT INTNE PETOIRMANCE OF THE WOIK fOR WNgI/ <br /> T �ERMR IB ISSUED.1 SHALL NOT EMPLOY ANY PERSON M SUAMUST <br /> S TO B C BVB CT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> B :ONTRUCTING BgNATVRE CERTIIIEB TIIE FOLLOWING:'I CERTIFY11E ANC OF THE WORN FOR WHICH THIS PERMIT IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECT 70 <br /> WISI�CMAN'B CO NBATgN LAWS OF CAUFOIWIA. THE APPI. I ADVANCE FOR ALL REGURED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> �!Z — DATE:PL T PAALE)SCALE1.r�AMEB OF BTRIEETB ORROADS NEAREST TO OR BOVNDINO 71e4.LOCATION OF HOUSE BEWAOE DISPOSAL SYSTEM OR PROPOSED <br /> EXPANS N OF SEWAGE Oil SAL SYBTTMS. <br /> ].OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, THE PROPERTY OR AD NO PROPERTY. <br /> .+LUDING COVERED AREAS SUCH All PATIOS,DRIVEWAYS,AND WALKS. _ <br /> I Q <br /> 9� <br /> - 7s 5s <br /> It <br /> 0 <br /> r <br /> 1 0 <br /> FOR DEPARTMENT USE ONLY <br /> -�/ �G DATE: /Z(J��/ L/LJ ARCA: J <br /> APPLICATION ACCEPTED flV <br /> DATE l <br /> -'X,RT OR BUMP INSPECTION BY <br /> DATE / / FINAL INSPECTION BY 7J (;/.E lIS(P • <br /> ITIONAL COMMENT B:- rT" //u t� <br /> � /'{ /J10�//J c� `•wGcJ� /I/i fj�h Lr✓�' F<yi� Fi>r�t:.s <br /> ACCOIMNNG ONLY: I Al.. FAG/ <br /> PE CODE FEE INFO AMOUNT REMIITED CHECK./CASH RECEIVED BY DATE BR I PEI"T NUMBER INVOICE. <br /> yz/ 2s - 721 z �-� <br /> Pub.Health So--Envvo.174(3/96) <br />